Implementation and Evaluation of a Clinical Practice Guideline for Hypoglycemia Management in Hospitalized Patients: A Quasi-Experimental Study

Kannikar  Yingyuen; Suranut Charoensri; Khamphon Satyawong; Worawut  Namdaeng; Nittaya Panphet; Chanpen Sripan

doi:10.60099/prijnr.2026.280477

Authors

Kannikar Yingyuen Nursing Department, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand.
Suranut Charoensri Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand.
Khamphon Satyawong Nursing Department, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand.
Worawut Namdaeng Nursing Department, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand.
Nittaya Panphet Nursing Department, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand.
Chanpen Sripan Clinical Laboratory, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Thailand.

DOI:

https://doi.org/10.60099/prijnr.2026.280477

Keywords:

Advanced practice nurse, Clinical practice guideline, Diabetes, Hypoglycemia, Implementation research, Management

Abstract

Evidence remains limited regarding how a context-adapted hypoglycemia management guideline can be implemented in routine inpatient practice and whether such an implementation can improve care processes and patient outcomes. This quasi-experimental study evaluated the implementation of an adapted clinical practice guideline for hypoglycemia management at a tertiary care hospital in northeast Thailand. The study included a retrospective three-month pre-implementation baseline period (January–March 2024), a one-month nurse training and preparation phase (May 2025), and a three-month post-implementation period (June–August 2025). Participants included 245 hospitalized patients with at least one hypoglycemic episode (pre-implementation, n = 138; post-implementation, n = 107) and 137 nurses who implemented the guideline. The guideline was adapted from the Diabetes 2023 Clinical Practice Guideline of the Diabetes Association of Thailand to align with the local hospital's resources, care processes, and practice environment. Implementation included structured preparation, dissemination of resource materials, nurse training, guided practice using the guideline manual, competency assessment, and integration into routine clinical care. Effectiveness was evaluated by comparing hypoglycemia-related clinical indicators, appropriateness of management, treatment-related costs, and nurse satisfaction before and after implementation.
Following implementation, the incidence of severe hypoglycemia (blood glucose <54 mg/dL) significantly decreased from 7.0 to 2.8 episodes per 1,000 patient-days. Mean blood glucose at detection significantly increased from 58.6 to 62.9 mg/dL, indicating earlier recognition. Appropriate hypoglycemia management increased from 7.3% to 47.1%, and overtreatment with excessive carbohydrate decreased from 40.8% to 23.0%. The average cost of hypoglycemia treatment per episode decreased from 8.35 to 4.26 Thai baht (0.25 USD to 0.13 USD). Nurses demonstrated 100% adherence to hypoglycemia surveillance among high-risk patients, and 70.1% reported high satisfaction with the guideline. In conclusion, implementation of the adapted hypoglycemia management guideline improved the quality and safety of inpatient care. Further multicenter studies are needed to evaluate implementation in other hospital settings.

References

Hulkower RD, Pollack RM, Zonszein J. Understanding hypoglycemia in hospitalized patients. Diabetes Manag Lond Engl. 2014 Mar;4(2):165–76. doi:10.2217/DMT.13.73

Yeh HF, Chao WC, Wu CL, Chan MC. Hypoglycemia and hospital mortality in critically ill patients. Sci Rep. 2025 Jan 21;15(1):2642. doi:10.1038/s41598-025-87163-9

Pratiwi C, Mokoagow MI, Made Kshanti IA, Soewondo P. The risk factors of inpatient hypoglycemia: A systematic review. Heliyon. 2020 May 1;6(5):e03913. doi:10.1016/j.heliyon.2020.e03913

Kuragayala SD, Nayak S, Khatib K. Hypoglycemia in hospitalized patients: A sleeping monster. Muller J Med Sci Res. 2024 Jun;15(1):5. doi:10.4103/mjmsr.mjmsr_81_23

American Diabetes Association. Standards of medical care in diabetes-2022 abridged for primary care providers. Clin Diabetes Publ Am Diabetes Assoc. 2022 Jan;40(1):10–38. doi:10.2337/cd22-as01

Yun JS, Park YM, Han K, Cha SA, Ahn YB, Ko SH. Severe hypoglycemia and the risk of cardiovascular disease and mortality in type 2 diabetes: a nationwide population-based cohort study. Cardiovasc Diabetol. 2019 Aug 14;18(1):103. doi:10.1186/s12933-019-0909-y

Kwan TN, Zwakman-Hessels L, Marhoon N, Robbins R, Mårtensson J, Ekinci E, et al. relative hypoglycemia in diabetic patients with critical illness. Crit Care Med. 2020 Mar;48(3):e233–40. doi:10.1097/CCM.0000000000004213

ORIGIN Trial Investigators, Mellbin LG, Rydén L, Riddle MC, Probstfield J, Rosenstock J, et al. Does hypoglycaemia increase the risk of cardiovascular events? A report from the ORIGIN trial. Eur Heart J. 2013 Oct;34(40):3137–44. doi:10.1093/eurheartj/eht332

Tan HK, Flanagan D. The impact of hypoglycaemia on patients admitted to hospital with medical emergencies. Diabet Med J Br Diabet Assoc. 2013 May;30(5):574–80. doi:10.1111/dme.12123

Aggarwal AK, Bajpai RG. A six-month prospective audit of hypoglycemia in non-critically ill inpatients at a tertiary care hospital in north India: prevalence, presentation, and prevention. Cureus. 2024 Nov;16(11):e74629. doi:10.7759/cureus.74629

Majić K, Car M. Knowledge and attitudes of Croatian nurses toward hypoglycemia management: A cross-sectional study. Diabetology. 2025 Jul;6(7):65. doi:10.3390/diabetology6070065

Coats A, Marshall D. Inpatient hypoglycaemia: a study of nursing management. Nurs Prax N Z Inc. 2013 Jul;29(2):15–24.

The Royal College of Physicians of Thailand; Diabetes Association of Thailand under the Patronage of Her Royal Highness Princess Maha Chakri Sirindhorn; Endocrine Society of Thailand; Department of Medical Services; and National Health Security Office. (2023). Clinical practice guidelines for diabetes 2023. Diabetes Association of Thailand under the patronage of Her Royal Highness Princess Maha Chakri Sirindhorn.

American Diabetes Association Professional Practice Committee for Diabetes. Diabetes care in the hospital: Standards of care in diabetes 2026. Diabetes Care. 2025 Dec 8;49(Supplement_1):S339–55. doi:10.2337/dc26-S016

Munoz M, Pronovost P, Dintzis J, Kemmerer T, Wang NY, Chang YT, et al. Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice. Jt Comm J Qual Patient Saf. 2012 May;38(5):195–206. doi:10.1016/s1553-7250(12)38025-2

Stewart M. Recognising and managing hypoglycaemia in adults with diabetes in the emergency department. Emerg Nurse. 2025 Mar 4;33(2):35–42. doi:10.7748/en.2025.e2223

Cohen M, de Grandpre K, Herlihy WM, Cooper L. Initiating an insulin safety campaign to reduce the incidence of glycemic harm events for hospitalized adults 65 and older. J Am Geriatr Soc. 2025 Feb;73(2):602–11. doi:10.1111/jgs.19193

Araque KA, Kadayakkara DK, Gigauri N, Sheehan D, Majumdar S, Buller G, et al. Reducing severe hypoglycaemia in hospitalised patients with diabetes: Early outcomes of standardised reporting and management. BMJ Open Qual. 2018;7(2):e000120. doi:10.1136/bmjoq-2017-000120

Shea KE, Gerard SO, Krinsley JS. Reducing hypoglycemia in critical care patients using a nurse-driven root cause analysis process. Crit Care Nurse. 2019 Aug;39(4):29–38. doi:10.4037/ccn2019876

Robinson A, Mathiason MA, Manchester C, Tracy MF. Evaluation of nurse-driven management of hypoglycemia in critically ill patients. Am J Crit Care. 2024 May 1;33(3):218–25. doi:10.4037/ajcc2024320

Curtis K, Fry M, Shaban RZ, Considine J. Translating research findings to clinical nursing practice. J Clin Nurs. 2017 Mar;26(5–6):862–72. doi:10.1111/jocn.13586

Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011 Mar;38(2):65–76. doi:10.1007/s10488-010-0319-7

Harrison MB, Légaré F, Graham ID, Fervers B. Adapting clinical practice guidelines to local context and assessing barriers to their use. CMAJ. 2010 Feb 9;182(2):E78-84. doi:10.1503/cmaj.081232

Dusitsin N, Aontuam Y. Principle and guideline for operations research work. Thai J Health Res. 2003;17(2):99-110.

Meechin N, Surit P. Effects of a nursing practice guideline for diabetic patients hospitalized with hypoglycemia on recurrent hypoglycemia, length of stay and readmission. J Nurs Health Care. 2018;36(3):157–65. Available from: https://he01.tci-thaijo.org/index.php/jnatned/article/view/151829 (in Thai).

Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care. 2003 Jun;26(6):1902–12. doi:10.2337/diacare.26.6.1902

Maynard GA, Childers D, Holdych J, Kendall H, Hoag T, Harrison K. Improving glycemic control safely in non-critical care patients: A collaborative systems approach in nine hospitals. Jt Comm J Qual Patient Saf. 2017 Apr;43(4):179–88. doi:10.1016/j.jcjq.2017.01.003

Saikawa R, Yamada H, Suzuki D, Amamoto M, Matsumoto Y, Funazaki S, et al. Risk factors of hypoglycemic encephalopathy and prolonged hypoglycemia in patients with severe hypoglycemia. J Clin Med Res. 2019 Mar;11(3):213–8. doi:10.14740/jocmr3728

Monthee K, Soivong P, Udomkhamsuk W. The effectiveness of implementing clinical practice guidelines in promoting advanced care planning for cancer patients receiving palliative care: Implementation research. Biomed Sci Clin Med. 2021 Oct 1;60(4):675–93.

Fontaine G, Vinette B, Weight C, Maheu-Cadotte MA, Lavallée A, Deschênes MF, et al. Effects of implementation strategies on nursing practice and patient outcomes: A comprehensive systematic review and meta-analysis. Implement Sci IS. 2024 Sep 30;19(1):68. doi:10.1186/s13012-024-01398-0

Huang X, Wang C, Lu L, Chen J, Wang R, Feng Y, et al. The effect of implementation leadership training for nursing informal leaders in the evidence-based practice. Front Med. 2025;12:1631810. doi:10.3389/fmed.2025.1631810

Xiong B, Stirling C, Bailey DX, Prudon P, Martin-Khan M. Implementation strategies of a national standard for comprehensive care in acute care hospitals: An interview study. Int J Nurs Sci. 2025 Jul 1;12(4):369–78. doi:10.1016/j.ijnss.2025.06.002